Shantrell Wilson

PerformRx is a Pharmacy Benefits Manager (PBM) for AmeriHeatlh Caritas dedicated to clinical culture, boutique service, and holistic solutions. My mission is to help clients, providers, and members use effective medication therapy to improve health and wellness. Primary responsibilities are to provide front-line customer support for a diverse portfolio of customers, mainly handling inbound telephone inquiries from Members, pharmacies, and Prescribers in their National Customer Care Center, and will consistently meet established productivity, schedule adherence, and quality standards. Also, Provide real-time support to pharmacies with point-of-service inquiries. Educate prescribers on formulary and prior authorization processes. Enter customer data and other relevant information into the documentation tool. Assist members with pharmacy benefit inquiries. Adhere to standard operating procedures to ensure contact handling accuracy and operational effectiveness. Effectively communicate issues and resolutions to customers and appropriate internal staff. 2024 Achieved World Class Customer Service Representative Award

• Assisted pharmacists in preparing and dispensing medications accurately.
• Maintained inventory levels, ensuring availability of essential pharmaceuticals.
• Processed prescription orders electronically, minimizing errors and improving workflow efficiency.
• Consulted with insurance company representatives to complete claims processing, resolve concerns, and reconcile payments.

• Reviewing insurance benefits and processing pharmacy claims. Processing Rx claims through express scripts. Reviewing Specialty Medication benefits under insurance to see if billing is processed through the medical side or pharmacy side of insurance. Attaching the correct beneficiary insurance information to promptly process the pharmacy claim. Updating patient information as necessary. Making OBC to pharmacies and provider offices to obtain insurance information to process medication to better understand coverage determination. Running Dummy claims to see if the insurance is correct or not. Sending fax to obtain necessary information needed to bill claim on the medication. Keeping a log of patient claims to ensure they are billed accurately day by day. Urgent claims that need to be processed within 10days. Reaching out to providers if medication requires a Prior Authorization to process ASAP to the insurance for plan coverage. Keeping Excel spreadsheets regarding a log of claims processed daily.

• Clinical Prior Authorization Technician. Certified Prior Authorization Specialist. Staying up to date on health care information and diagnosis and new to market specialty medication needs. Processing Mock Claims on specialty medications to see if insurance coverage is available through the PBM. Reviewing to see if specialty medications requires a Prior Authorization (PA). Analyzing multiple insurance plans and their coverage guidelines of specialty medications based upon insurance criteria that must be met in order for the medication to be supplied to the patient based upon insurance. Obtaining PA notes and review medical information in order to process PA through the insurance. Ensuring that provider and patient information is accurate before processing PA. Making sure to keep up with the TAT based on insurance processing time to ensure CVS does not get fined by the client (Insurance) by not providing coverage determination within a specific time frame. Working with Aetna, BCBS, FLBL, Etc. Insurance companies to problem solve regarding insurance coverage. Working with appeals team regarding denied PA’s. OBC to Medical facilities to obtain clinical information to complete unfinished PA’s. Hands on with Cover my meds and creating Keys and troubleshooting errors. Checking Excel Spreadsheets max daily dose and max supply of specialty medications based on medical guidelines to complete overrides. Denying or Approving PA’s for specialty medications.
• Collaborated with healthcare professionals to optimize patient care plans.
• Educated patients on medication usage, enhancing understanding and compliance.

• Certified Pharmacy Technician working as a Harris Teeter employee, answering phone calls into the pharmacy, taking prescription orders, and transferring prescriptions to other pharmacies. Managing inventory, ordering prescriptions, and checking in the order. Keeping up with invoices, making sure it is marked up with the weekly percentage and close out the weekly values. Counting and refilling prescriptions, checking for patient medication therapy management. Informing patients that they are eligible to receive vaccines based upon checking their health history in NCIR (North Carolina Immunization Registry). Keeping up with Covid-19 protocols and precautions. Filing and keeping up with records and important documents that need to be filed. On a Retail spectrum, making sure that the general manager has our numbers before the end of the week to process the week. Checking out customer, guiding customers to products within the store. Keeping up customer service, and following protocols for each customer helped, to make sure secret shopper questions are all marked. Within a year of employment was granted by the Pharmacy News Today, an award for Pharmacy Technician of the Month in 2019 in North Carolina. https://www.pharmacynewstoday.com/pharmacy-tech-of-the-month/north-carolina-Shantrell-Wilson-2019-10-31

• Informing home owners the 3 main aspects of the opportunity to go solar. Documenting customers information in an excel format. Appointing a coordinator to the home address at an appointment time available throughout the week. Keeping up with contacts to inform supervisor appointment was set, and information was given to them sufficiently also successfully. Maintain contracts of the client in regards to them moving forward. Goal was to have 100% satisfaction with the client from beginning to end.

• Main contact for Humana. Humana Mail-Order Pharmacy. Taking inbound calls giving members information on their coverage of insurance for prescriptions. Running claims to give cost of prescriptions using Citrix. Relating aspects of their Health Benefit based off their insurance. HMO/PPO/ PPE insurance policies. Placing refill prescription orders. Calling CVS/WALGREENS/ WAL-MART Pharmacy/ KROGER pharmacy/ local pharmacies to reverse claims that were not being processed (this was an action that only my supervisor advised me to do) being that I knew what I was doing and maintaining members accounts, I had access to approval codes that gave me authorization to correct mistakes on members accounts. Giving details of the prescription when shipping an order. Dealing with MAPD, PDP insurance. Web Emulation. Warm transferring calls. I was (I.T.) for my team with any troubleshooting issues with computers. Manager and Supervisor made me the Team Leader/ SME (subject, matter, expert) which I was the first person to go to for any help, rather if a member wanted to speak with someone other than the agent, before the supervisor.
• Improved customer service ratings by addressing concerns promptly and professionally.

• Gathering health information from residence to help Govern Health Reform for the state of California. Informing residents of certain Health Insurance Policies. Reading information verbatim based upon their location and the region of the area. Data collected was set to a specific time frame. Calls were randomized by a computer; outbound calls were divided to (house hold/cellular) calls. I worked both contracts and Received a Kermit Award, for being knowledgeable, engaging, resourceful, maintained, interactive, and transcending, with great customer service. I also worked in Operations, which was the distribution center for mailing forms and money to participants.

• Worked my way up to being a manager assistant. Counting the safe and dropping off the deposit. Setting schedules for the crew and taking appropriate action towards insubordination.

• Introducing a party to their table. Organizing tables and bars based on the amount of guest for an event. Designing to a specific theme and picking color schemes. Taking calls based upon specific needs of a member. Organizing mail and calling members to inform them of their packages. Managing organization of documents in alphabetical order and filing. Made such a remarkable impression I earned a scholarship.